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WRIST AND HAND COMPLEX

Amputated hand:
o 90% function of UE is gone 1. Capitate
Proximal Joints serve the hand aka Os Magnum
Control length tension relationship in multiarticular joint Largest carpal bone
and muscles to allow fine adjustment of grip At birth/after birth
o Balance and Control Axis of motion for ulnar/radial deviation
Most complex joint in the body:
o Wrist Joint 2. Hamate
2 of freedom aka Uncinate
Normal ROM: Immediately after capitate/at birth
o Flexion: 0-80
o Extension: 0-70 3. Triquetrum
o Abduction: 0-20 aka Triangular
o Adduction: 0-30 2 years old
Axis of motion for wrist flexion/extension
JOINTS
3rd most commonly fractured bone
1. Radiocarpal Joint
Main wrist joint 4. Lunate
Between radius and scaphoid, lunate, and Aka Semilunar
triquetrum
3 years old
Joint Classification:
Most commonly dislocated bone
o Ellipsoid
2nd most commonly fractured bone
Radius extends more distally than ulna Special Test: Murphys Sign Test

2. Midcarpal Joint 5. Scaphoid


Between proximal and distal carpal row aka Navicular
Pisiform not included 5-6 years old
Joint Classification: Most commonly fractured bone
o Condyloid 2nd most dislocated bone
Largest carpal bone in proximal row
BONES Proximal floor of anatomic snuff box
Carpals = 16 Special Test: Cascade Sign
Metacarpals = 10
Phalanges = 28 6. Trapezoid
aka Lesser Multangular
IMPORATANCE OF 2-JOINT SYSTEM 5-6 years old
Permits large ROM
Less tendency of impingement 7. Trapezium
Allow distribution of pressure withstanding greater
aka Greater Multangular
pressure
5-6 years old
Distal floor of anatomical snuff box
CARPAL BONES
8. Pisiform
Proximal Row:
10-12 years old
o Scaphoid, lunate, triquetrum, pisiform
Distal Row: Sesamoid bone (bone over a tendon)
o Trapezium, trapezoid, capitate, hamate Only carpals with muscle attachment
Bikers Palsy
Base order of Ossification:
o Capitate hamate triquetrum lunate
scaphoid trapezoid trapezium
pisiform

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RADIOCARPAL JOINT
Articulations: Radius & Proximal carpals
Biconcave: Radius LIGAMENTS
Biconvex: Carpals 1. Dorsal Carpal Ligaments
Proximal Joint Surface: Volar radiocarpal
o Lateral radial facet Radiocaphocapitate
o Medial radial facet Radiocapholunate
o TFCC Radiolunate
Oblique and slightly angled volarly (palm) & ulnarly
Average inclination of distal radius volarly: 2. Dorsal Carpal Ligaments
o 11 Dorsal radiocarpal ligament
Average inclination of distal radius ulnarly: Dorsal intercarpal ligament
o 23
3. Greysons & Clelands Ligament
Triangular Fibrocartilage Complex (TFCC) Fix skin to bone of fingers
Attachment: Important for grasping objects
o Distal radius
o Ulnar styloid process MOTIONS OF THE WRIST
o Triquetrum Combination of active (contaction of mm) and passive
Function: (movement of ob bones) structure
o Binds radius & ulna 3 segment linkage:
o Separates distal RU joint and ulna from o Radius
radiocarpal joint o Proximal carpal row
Special Test: Supination Lift Test o Distal carpal row

Ulnar (-) vs Ulnar (+) variance Proximal Carpal Row


Ulnar (-) Ulnar (+) Intercalated segment
Length of Ulna Short Long Needs stabilization
TFCC Thick Thin Scaphoid greatest motion
Problem - Abnormal Impingement
distribution of 1. Wrist Extension
forces Distal carpal row glides posteriorly on proximal
- Degeneration carpal row
- Krenbocks Scaphoid and distal row move
Treatment Unloading of Joint leveling Carpals move as a unit on radius
RC Joint
2. Wrist Flexion
LIGAMENTS AND CAPSULE Vice versa (anteriorly)
Capsule is strong but loose
Reinforced by capsular & intracapsular ligaments 3. Radial/Ulnar Deviation
Extrinsic Ligaments Unique reciprocal motion of proximal carpal
o Connects carpals radius/ulna Radial deviation:
Intrinsic Ligaments o Proximal row goes ulnarly
o aka Intercarpal/Interosseus Ulnar deviation:
o Interconnect the carpals o Proximal row goes radially

Stronger: Intrinsic (more compact) Flexion = 80


Nutrition: Extrinsic (have own blood supply) RC joint = 50
MC joint = 35
First to fail: Extrinsic
Extension = 70
Better potential for healing: Extrinsic
RC joint = 35
MC joint = 50
Radial Deviation = 20

2
RC joint = 10 Tunnel of Guyon
MC joint = 10 - between pisiform and hamate
Ulnar Deviation = 30
Piso-hamate Ligament
RC joint = 20 MC joint = 10
- where ulnar nerve passes through
INSPECTION OF THE HAND
SENSORY DISTRIBUTION OF HAND
- Complete number of fingers
1. Palmar Aspect:
- attitude of the hand
o Median nerve lateral 3
- damaged flexor tendon
o Ulnar nerve medial 1
- contour of the palmar surfaces
2. Dorsal Aspect:
- 3 arches
o Median nerve lateral distal 3
- hills and valleys (bulges)
o Radial nerve lateral proximal 3
- knuckles
o Ulnar nerve medial
- nails
B. Wrist Extensors
ARCHES OF THE HAND
o ECRL, ECRB, ECU, EDC, EDM, EI, APL, EPB, EPL
Distal Transverse Arch
Longitudinal Arch Mobile Wad of 3 or Henry: brachioradialis, ECRL,
Oblique Arch ECRB

PALMAR CREASES
Extensor Retinaculum
Wrist crease - holds extensor tendons
Thenar crease - divides tendon into 6 tunnels
Proximal/Distal Palmar Crease
Palmar Digital Crease Extensor Tunnels
Proximal/Distal Interphalangel Crease o Tunnel 1 APL, EPB
o Tunnel 2 ECRL, ECRB
SURGICAL NO MANS LAND o Tunnel 3 EPL
Landmark: Distal Palmar Crease o Tunnel 4 ED, EI
: Proximal Interphalangeal Crease o Tunnel 5 EDM
- must not go surgery because of very poor blood o Tunnel 6 ECU
supply
De Quervains/Stenosing Tenosynovitis
MUSCLES OF THE WRIST COMPLEX - Tunnel 1
- provides stable base for the hand
Radial border of Anatomical Snuff Box
A. Wrist Flexors - Tunnel 1
o Palmaris Longus, FCR, FCU, FDS, FDP, FPL - lateral: APL
- medial: EPB
Flexor Retinaculum
- holds/binds flexor tendons at wrist area Ulnar border of Anatomical Snuff Box
- Above: Palmaris Longus, FCU - EPL (Tunnel 3)
- Below: Transverse Carpal Tunnel
Tennis Elbow
Structures that passes beneath Flexor Retinaculum: - Tunnel 2 (ECRB most affected)
o 4 tendons of FDS
o 4 tendons of FDP Hex Sign
o 1 tendon of FPL - Tunnel 4 (individual action of ED & EI)
o Median Nerve
o FCR

Carpal Tunnel
- area beneath Transverse Carpal Ligament
Carpal Tunnel Syndrome median nerve is
affected

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SPECIFIC MUSCLE ACTIONS MCP Joint
Palmaris Longus pure wrist flexor; used as tendon - Formed by head of metacarpal and base of proximal
grafts phalanx
FCU has greatest tension - Joint classification: condylar
FDS flexes wrist if fingers are flexed; wrist flexor - 2 degrees of freedom
FDP finger flexor Motions: flexion/extension, abduction/adduction
FPL wrist radial deviation Range of Motion: flex/ext; abd/add
ECRB strongest wrist extensor o Flexion/Extension
ECRL strong radial deviator MCP
elbow flexor w/ in neutral PIP
ECU wrist extensor affected by FA position; can also DIP
flex the wrist if FA is neutral/pronated Thumb MCP
EDM extends 5th digit Thumb IP
EI extends 2nd digit Thumb CMC
EDC pure finger extensor (2nd 5th digit); flexion/extension,
extends wrist if fingers are extended abduction/adduction

HAND COMPLEX SOFT TISSUE SUPPORT


- 5 digits (each has MCP joint) 1. Volar Plate
- finger have PIP and DIP - Between head of metacarpal and proximal phalanx
- Increases congruency of MCP joint
- Provides stability for MCP Joint
Proximal Interphalangeal Joint between proximal
- Limits hyperextension of digits
and middle phalanx
Distal Interphalangeal joint between distal and
2. Collateral Ligaments
middle phalanx
- Limits side to side movement of IP Joint
- Increase congruency of bony structures of
- Amputated thumb: 40-50% function
- Stability to hand
- Amputated index finger: 20%
- Limits hyperextension (extension is not
- Amputated 4th/5th finger: 10%
functional)
- Protects volar musculature
CMC Joint of FINGERS
- Distal carpal row and 2nd-5th metacarpal
3. Deep Transverse Metacarpal Ligament
- between distal carpal row and base of
Deep transverse Metacarpal Ligament
metacarpals
- Stability of CMC joint
- limits spreading of fingers
Proximal transverse carpal arch
- Type of Prehension: Power Grip
Greatest motion: 5th finger
TYPES OF GRIP:
CMC Joint of THUMB
Power Grip
- Formed by trapezium and 1st metacarpal base
- most mm (2nd - 5th digits) are working
- Joint classification: saddle joint
- needs transverse metacarpal ligament
- Capsule: very loose and thick
o hook
- 3 degrees of freedom
o cylinder
o fist
Motions parallel/perpendicular to palm:
o spherical
1. Parallel flexion/extension
2. Perpendicular abduction/adduction
Precision/Prehension Grip
Caused by trapezium
- uses 2/3 fingers only
Most common site of
o Chuck/3-hinged pinch (digital
osteoarthritis
prehension)

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o Lateral/Key Pinch (lateral
prehension)
o Tip Pinch

*Hand Dynamometry measures grip


EXTRINSIC FLEXORS:
HAND MUSCULATURE FDS (inserts until PIP), FDP (inserts until DIP), FPL
A. EXTRINSIC
a. Flexors Action:
FDS, FDP flexion of finger FDS finger and wrist flexion
FPL flexion of thumbs FDP wrist flexion and 2nd-5th finger flexion
FPL thumb flexion
b. Extensors
EDC, EIP, EDM, EPL, EPB, ADL More Active:
FDP (finger) more active, FDS (wrist) contracts if
B. INTRINSIC greater force is needed
a. Median nerve At the level of MCP: FDS is more active
Thenar: Abductor Pollicis Brevis, Level of PIP: FDP is more active
Flexor Pollicis Brevis, Opponens
Pollicis (for opposition), Adductor *Ruptured FDP (no DIP flexion)
Pollicis (APB, FPB, OP, AP)
Lumbricals: Flexion of MCP with IP Sweater Finger Sign
extension; space between fingers - absent FDS
- no PIP flexion
b. Ulnar Nerve
Hyopthenar: Abductor Digiti Minimi, FLEXOR MECHANISM
Flexor Digiti Minimi, Opponens Digiti o Flexor retinaculum, deep transverse metacarpal
Minimi (ADM, FDM, ODM) ligament, annular (round) and cruciate (crossed)
Interossei: pulleys
o Palmar Adduction (PAD) - forms tunnels; (+) bursa of the fingers are
o Dorsal Abduction (DAB) found
Palmar Brevis: assists in finger flexion - prevents bowstringing of tendon
- increase efficiency of contraction of finger
*EPL cannot function w/o ADL flexors
- infection may travel through tendon sheaths

EXTRINSIC EXTENSORS:
EDC, EIP, EDM

Length: Forearm to extensor retinaculum


at the MCP level: EDC merges with extensor
mechanism
EDC combines with the EIP and EDM

Junctura Tendinae
- connects 2 tendons of EDC

EXTENSOR MECHANISM
o aka Extensor expansion, apparatus, extension
aponeurosis, retinaculum, extension mechanism,
dorsal hood
- termination of almost all digital extensors
and intrinsic muscle (except ECU)
- No tendons in the digits

DIGITS Extensor hood

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Primary muscle: EDC, Interossei, and Lumbricals
Extensor Hood: assistst in hand opening or finger extension
EDC
- crosses MCP joint and inserts to base of proximal
phalanx
- will give off 3 bands (2 lateral, 1 central)
Lateral band/slip: continue to rejoin over the
middle phalanx and inserts to the base of
distal phalanx
Central band/slip: inserts to the base of
middle phalanx
Interossei attaches to the base of proximal and middle
phalanx, volar plate, and lateral bands
Lumbricals inserts to lateral slip

HAND CLOSURE/OPENING
Light hand closure
o unresisted
o FDP
Foreceful closure
o resisted
o FDS, FDP, and Interossei
Hand Opening
o ED

SPECIFIC ACTION OF MUSCLES


EDC MCP joint hyperextension, IP extension
Lumbricals MCP flexion, IP extension
FDP IP flexion
FDS PIP flexion
Interossei abd/add of hand
FPL only flexor of thumb IP
adductor of the abducted thumb
Thenar muscle unresisted opposition, MCP flexion,
CMC abduction